COB Routine Secondary Allowances
Signature, Choice and Advantage Secondary Allowances
|
Service |
VSP Signature and VSP Choice |
Advantage |
|---|---|---|
|
Eye exam |
$66 less secondary plan copays |
$50 less secondary plan copays |
|
Lenses |
$51 less secondary plan copays |
$36 less secondary plan copays |
|
Frame |
$76 less secondary plan copays |
$58 less secondary plan copays |
|
Maximum for Exam, Lens and Frame |
$193 less secondary plan copays |
$144 less secondary plan copays |
Secondary allowances are less secondary plan copays and are cumulative.
Other Secondary Allowances:
- For patients with an Elective Contact Lens Benefit, refer to the Patient Record Report for the contact lens allowance. (Note: A covered-in-full contact lens exam does not have a secondary COB dollar value).
- For patients with allowance plans, refer to the Patient Record Report for the material allowance.
- You can coordinate the secondary exam allowance with the exam, refraction and/or retinal screening out-of-pocket expense from the primary plan.
Medicaid Network Coordination of Benefits Secondary Allowances
Refer to your Medicaid Manual for state-specific Medicaid COB guidelines.
Applying Allowance Examples
VSP to VSP for Exam, Lens and Frame
|
Here’s a VSP Signature Plan example: |
||
|---|---|---|
|
Calculate the patient’s out-of-pocket expenses under their primary plan |
||
|
Exam copay |
$10 |
|
|
Lens copay + lens enhancements |
+ $133 |
|
|
Frame overage: |
+ $122 |
=$265 |
|
VSP will COB the patient’s out-of-pocket expenses up to secondary allowance: |
||
|
Maximum for Exam, Lens and Frame secondary allowance: |
$193 |
|
|
Lens secondary plan copay |
- $20 |
-$173 |
|
Patient pays remaining balance |
= $92 |
|
Health Plan or Medicare, VSP secondary for Exam and Refraction using WellVision Exam benefit
|
Here’s a VSP Choice Plan example: |
Exam |
Refraction |
|---|---|---|
|
Bill the health plan or Medicare your U&C fee |
$120 |
$35 |
|
Determine Other Insurance Allowed Amount |
$100 |
Not covered |
|
Subtract the Other Insurance Paid Amount: |
- $75 |
$0 |
|
VSP will COB the patient’s out-of-pocket expenses up to this amount (Other Insurance Pat Responsibility): |
= $25 |
= $35 |
|
Balance submitted as secondary claim to VSP |
$60 |
|
|
VSP pays up to the secondary allowance $66, less secondary plan copays |
- $60 |
|
|
Patient pays remaining balance |
= $0 |
|
|
Note: Provider is paid $135 for exam and refraction ($75 from health plan/Medicare + $60 VSP). If the primary plan’s allowed amount is lower than U&C, subtract the primary plan’s paid amount from allowed amount to determine the patient’s responsibility. |
||
Health Plan or Medicare, VSP secondary using WellVision Exam and Essential Medical Eye Care
|
Here’s a VSP Choice Plan example: |
Exam |
Refraction |
Fundus |
|---|---|---|---|
|
Bill the health plan or Medicare your U&C fee |
$120 |
$35 |
$80 |
|
Determine Other Insurance Allowed Amount |
$100 |
Not Covered |
Not Covered |
|
Subtract the Other Insurance Paid Amount: |
- $75 |
$0 |
$0 |
|
VSP will COB the patient’s out-of-pocket expenses up to this amount (Other Insurance Pat Responsibility): |
= $25 |
= $35 |
=$80 |
|
Balance submitted as secondary claim to VSP |
$35 |
$80 |
|
|
VSP pays up to the secondary allowance $66, less secondary plan copays |
- $35 |
Essential Medical Eye Care Fees* |
|
|
Patient pays remaining balance |
= $0 |
=$0 |
|
|
Note: Provider is paid $135 for exam and refraction ($75 from health plan/Medicare + $60 VSP) plus Essential Medical Eye Care Fee Schedule for medical service(s). If you perform a medical eye exam and services along with a refraction, you may now maximize the patient’s VSP coverage to coordinate using BOTH their medical and routine benefit to reduce their out-of-pocket. *VSP will pay up the Essential Medical Eye Care fee schedule, less applicable copay. If the service is not covered by the Other Insurance plan, VSP will process service as primary. |
|||
Coordination of Benefits by Network Participation
With the exception of the secondary allowances, the VSP Advantage Plan, VSP Enhanced Advantage Plan, and VSP Essentials Plan COB guidelines are the same as the VSP Signature Plan and VSP Choice Plan. If you’re not participating in the Advantage Network and the member wants to use their secondary plan to coordinate benefits, we’ll reimburse the patient based on their non-VSP provider reimbursement schedule (if out-of-network coverage is available).
|
Patient’s primary plan |
Patient’s secondary plan |
Your network participation is |
Then |
|---|---|---|---|
|
VSP Advantage Plan or VSP Essentials Plan |
VSP Signature Plan or VSP Choice Plan |
Advantage Network |
You’ll be reimbursed based on the VSP Signature and Choice COB allowances. (See COB Client Exception Rules for exceptions). |
|
VSP Advantage Plan or VSP Essentials Plan |
VSP Signature Plan or VSP Choice Plan |
Non-Advantage Network |
We’ll reimburse the patient based on their non-VSP provider reimbursement schedule if out-of-network coverage is available. |
|
VSP Signature Plan or VSP Choice Plan |
VSP Advantage Plan or VSP Essentials Plan |
Advantage Network |
You’ll be reimbursed according to the Advantage Secondary Allowances. |
|
VSP Signature Plan or VSP Choice Plan |
VSP Advantage Plan or VSP Essentials Plan |
Non-Advantage Network |
We’ll reimburse the patient based on their non-VSP provider reimbursement schedule if out-of-network coverage is available. |